University Hospitals Birmingham NHS Foundation Trust

6. Mrs K says the Trust missed opportunities to diagnose her mother, Mrs A’s, cancer during her hospital admission from 9 to 14 August 2023. She also says the complaint handling was poor.

7. Mrs A’s cancer was not diagnosed until December 2023, following a GP referral for deteriorating kidney function. By then, the cancer was advanced and only palliative care was possible.

8. Mrs K says although she accepts her mother may still have died from cancer, an earlier diagnosis could have given the family more time to prepare, explore treatment options such as chemotherapy or radiotherapy, and support Mrs A emotionally.

9. She says the late diagnosis meant the family had no opportunity to adjust, plan, or understand what was happening, and this caused significant distress. She also describes the impact on the family, including prolonged emotional suffering, the suddenness of the final weeks, and the ongoing effect on her father and siblings.

10. Mrs K says the Trust’s prolonged delays, lack of communication, and inconsistent responses to her complaint caused significant additional distress to the family at an already difficult time.

11. Mrs K wants the Trust to acknowledge opportunities were missed during the August 2023 admission, to apologise, to demonstrate learning so this does not happen to others, and to provide a financial remedy.

12. What follows is our summary of events. We have not included all the details as those involved are already aware of this information. We have included this brief background to put the complaint in context.

13. Mrs A was in her 60s at the time of these events. She had a medical history including type 2 diabetes, heart failure and arthritis, and was registered blind. On 31 May 2023, she had surgery to remove a benign pituitary tumour.

14. Mrs A was referred to the Trust’s Emergency Department by her GP on 9 August with fatigue, constipation, shortness of breath and a sixweek history of back pain. A recent blood test also showed her kidney function had deteriorated (her eGFR was 25, where a normal result is usually above 60).

15. Mrs A was admitted to a renal and diabetic ward. The Trust’s impression was that her symptoms were related to adrenal insufficiency (when the adrenal glands do not produce enough cortisol). After her symptoms improved, she was discharged home on 14 August.

16. On 19 September, Mrs A’s GP referred her to the Trust’s kidney (nephrology) service because her kidney function continued to decline.

17. Mrs A attended a nephrology appointment on 2 November. She was referred for an ultrasound scan, which took place on 23 November. This identified lesions on her liver, and she was referred for an MRI (magnetic resonance imaging) scan.

18. The MRI was completed on 30 November. Mrs A was diagnosed with stage 4 colorectal (bowel) cancer that had spread to her liver and the lining of her abdomen.

19. A colorectal multidisciplinary team reviewed her case on 4 December and concluded she was not suitable for surgery or chemotherapy. Her treatment was palliative care only.

20. Mrs A sadly died on 30 January 2024.

21. Mrs K raised a complaint with the Trust on 25 March 2024. After significant delays and correspondence between the family and the Trust, the Trust issued its final response on 23 June 2025.

Missed opportunities to diagnose cancer during the August 2023 admission

25. Mrs K says the Trust missed opportunities to diagnose her mother’s cancer during her admission from 9 to 14 August 2023. She says her mother presented with significant symptoms, including fatigue, severe back pain, constipation, reduced mobility and lack of appetite, and that these should have prompted further investigation, including scans. She also says an oncologist later told the family the cancer had been present ‘for some time’, which reinforced their belief that it should have been detected earlier.

26. The Trust explained when Mrs A was admitted, she had reduced kidney function, fatigue, constipation and shortness of breath. Because she had recently had surgery on the pituitary gland (a small gland in the brain that controls many hormones), the clinical team thought these symptoms were most likely due to adrenal insufficiency. This is a condition where the adrenal glands do not produce enough hormones, and it can happen after pituitary surgery.

27. The endocrinology team (hormonespecialist team) reviewed Mrs A, and her steroid and insulin medicines were adjusted, and her symptoms improved. The Trust said there was nothing about her symptoms at that time that suggested cancer, so they did not think scans of her abdomen were needed.

28. We reviewed Mrs A’s clinical records and asked our adviser to consider whether the Trust should have suspected cancer during this admission. They explained Mrs A did not present with the typical ‘red flag’ symptoms for colorectal cancer described in NICE guideline NG12, such as rectal bleeding, unexplained weight loss, persistent abdominal pain, or a change in bowel habit. Her symptoms were nonspecific and could reasonably be explained by adrenal insufficiency, which is a recognised complication after pituitary surgery.

29. However, our adviser identified concerns about how the Trust assessed and documented Mrs A’s anaemia. They noted although the Trust described her anaemia as longstanding and related to chronic kidney disease, several blood tests before and during the August admission showed microcytic and hypochromic red blood cells (meaning the red blood cells were smaller and paler than normal), which is typical of irondeficiency anaemia. Low iron levels were also documented on 12 July 2023. Ferrous sulphate was prescribed on discharge, indicating clinicians recognised iron deficiency, even though this was not recorded as a diagnosis.

30. Our adviser said irondeficiency anaemia is a recognised indicator that should prompt consideration of underlying causes, including colorectal cancer, even when other symptoms are absent. They explained recognising and responding to irondeficiency anaemia is basic clinical practice, and that GMC guidance requires clinicians to adequately assess a patient’s condition, document their reasoning, and arrange appropriate investigations where indicated. The Trust did not do this.

31. When the family met with a colorectal surgeon in January 2024, they were told Mrs A had been anaemic since 2022 and that this ‘may have been an early sign that something else was going on’. This is consistent with our adviser’s view that the pattern of microcytic, hypochromic anaemia should have prompted consideration of underlying causes, including gastrointestinal blood loss (bleeding from the stomach or bowel).

32. There was no documented attempt to explore the cause of the anaemia, nor any record of a conscious decision not to investigate further. Our adviser described this as a missed opportunity to consider whether further investigation was needed. They also said that even if Mrs A’s comorbidities meant invasive investigations were unlikely to be appropriate, this should have been considered, documented, and ideally discussed with the family.

33. We also considered whether earlier investigation of the anaemia would have changed either the clinical outcome or the family’s experience. Our adviser explained Mrs A’s cancer was already advanced by the time it was diagnosed in November 2023 and was likely present for some time before the August admission. They said her significant comorbidities, including cardiovascular disease, obesity and reduced kidney function, meant she was unlikely to have been a candidate for surgery, chemotherapy or radiotherapy even if the cancer had been diagnosed earlier.

34. However, our adviser considered it likely that an earlier diagnosis would have given the family more time to prepare and understand the situation, even though it would not have altered the clinical outcome. Earlier diagnosis may also have allowed earlier involvement of palliative care services, which could have provided additional support to the family during this period, even though it would not have changed the clinical outcome.

35. We agree with our adviser that the Trust did not adequately assess or document the cause of Mrs A’s irondeficiency anaemia. This fell below expected standards and represents a missed opportunity to consider whether further investigation was needed. While this would not have changed the clinical outcome, it contributed to avoidable uncertainty for the family and reduced the time they had to prepare for the eventual diagnosis.

36. Our view is that there was a failing in the Trust’s assessment and documentation of Mrs A’s anaemia. We do not consider this failing affected the clinical outcome, but it caused avoidable distress and uncertainty for the family, including the loss of an opportunity to have earlier awareness of the cancer diagnosis.

Complaint handling

37. Mrs K first raised a complaint with the Trust on 25 March 2024. She told us the prolonged delays and lack of communication caused significant distress at an already difficult time. She said the family felt they had to ‘constantly check emails’ and repeatedly chase the Trust for updates, and some emails were not acknowledged at all.

38. She said waiting ten months for the first response, only to receive a letter that raised further questions, was ‘deeply traumatising’ and prolonged their grief. The delays left them without answers about their mother’s care and contributed to ongoing feelings of guilt, doubt and ‘what if’ questions. One family member required counselling for over six months.

39. The family said the Trust’s lack of compassion in its communication, and the absence of timely updates, added to their distress. They told us the delays prevented them from achieving closure, particularly for Mr A, who was struggling with the sudden deterioration he witnessed in the final weeks of his wife’s life. They said the Trust’s handling of the complaint ‘created greater distress’ and made an already painful experience harder to cope with.

40. The records show the Patient Advice and Liaison Service forwarded the complaint to the Patient Relations team on 11 April 2024. The Trust told the family the complaint would be reviewed and investigated within 65 working days.

41. Before submitting their complaint, the family met with a colorectal surgeon in January 2024 to understand how Mrs A’s cancer had been diagnosed at an advanced stage. The surgeon explained Mrs A had been anaemic since 2022 and this might have been an early indication of another underlying issue. He was unable to answer all their questions and advised them to raise their concerns through the Trust’s complaints process. The family told us this reinforced their need for a clear explanation about their mother’s care.

42. Between July and November 2024, the Trust sent several emails apologising for delays, citing staff absence or the need for further medical input. On 18 July it said it needed ‘a couple more weeks’. On 29 August and again on 19 September it apologised for the delay, explaining a member of staff was absent and the investigation had taken ‘significantly longer than anticipated’.

43. On 10 October the Trust said it was still waiting for final medical input, and on 11 November it apologised again, saying it did not want to add to the family’s frustration but still required further information. During this period, the family sent multiple chasers, some of which were not acknowledged.

44. On 3 December 2024, we wrote to the Trust after the family reported ongoing difficulties obtaining a response. We explained we had previously asked the Trust, on 13 November, to contact the family with a final response by 27 November 2024 or to explain if no further action could be taken. Despite this, the Trust did not meet the deadline, and the family had to return to us for further assistance.

45. The Trust issued its first response on 9 January 2025, around ten months after the complaint was first raised. This response included a generic apology for the delay but did not explain why the investigation had taken so long or acknowledge the impact on the family.

46.  On 3 February 2025, the family sent further questions to the Trust. The Trust acknowledged this on 19 February and again advised a response would be provided within 65 working days.

47.  On 19 May 2025, Mr A emailed the Trust explaining it had exceeded its own timescale and had not acknowledged his earlier email. He said the lack of communication was ‘absolutely disgraceful’ and that the family had been waiting over 12 months ‘to understand why they lost their mother’.

48. On 21 May 2025, the Trust emailed the family acknowledging the second response had taken ‘an unreasonable amount of time’ and apologising for failing to respond to their earlier email. The Trust said the delay was due to difficulties finding a clinician to address the concerns about Mrs A’s anaemia, as the consultant involved was no longer employed by the Trust. The staff member said they had escalated the matter to the Medical Director due to their own concerns about the length of time the investigation was taking.

49. The Trust issued its second and final response on 23 June 2025. This response did not mention the delay at all, despite the family having waited a further four months and having chased for updates several times. In total, around 14 months passed between the initial complaint and the final response.

50. The NHS Complaint Standards say organisations should provide timely responses, keep complainants updated, acknowledge and address all issues raised, provide clear and evidence‑based explanations, demonstrate openness, accountability and learning, and communicate with compassion.

51. The Trust did not meet these standards. It took significantly longer than the 65 working days it had committed to, and there were long periods with no updates. Some of the family’s emails were not acknowledged. This fell below the expected standard of keeping complainants informed.

52. We recognise the tone of the Trust’s emails was polite and apologetic. However, compassion in complaint handling requires more than polite wording. The family were left without meaningful updates for long periods, some emails were not acknowledged, and the delays continued for over a year.

53. Despite repeated apologies, the Trust did not provide clear explanations, did not address key issues such as the anaemia, and did not demonstrate learning. This fell short of the NHS Complaint Standards and contributed to the family’s distress.

54. The Trust’s first response did not address all the issues raised. In particular, it did not explore or explain the concerns about the assessment of Mrs A’s anaemia, nor did it acknowledge the missed opportunity identified by our adviser. This meant the family were left without answers to key questions about their mother’s care.

55. Neither of the Trust’s responses explained why the iron‑deficiency anaemia was not investigated further, nor did they reflect on what should have happened. The Trust did not acknowledge this as a missed opportunity or demonstrate learning. Our adviser also noted the overall quality of the documentation was poor, the records were disorganised and difficult to follow chronologically, and the delay in the Trust’s complaint response was concerning.

56. While our adviser did not comment on the content of the complaint responses themselves, we consider these observations reinforce the seriousness of the shortcomings in how the Trust handled the complaint.

57. We consider the Trust’s complaint handling caused significant and avoidable distress. The prolonged delays, lack of communication and incomplete responses left the family without clarity about their mother’s care for over a year. This prolonged their grief, contributed to ongoing uncertainty, and meant they were unable to begin to process their loss. The family told us the experience was ‘unbearable’ at times, and we have no reason to doubt this.

58. Our view is that there was a failing in the Trust’s complaint handling. This caused avoidable frustration, uncertainty and emotional distress for the family at an already difficult time.

1. We have considered the concerns raised by Mrs K about her mother, Mrs A’s, care during the August 2023 admission at University Hospitals Birmingham NHS Foundation Trust (the Trust), and about the Trust’s handling of her subsequent complaint.

2. Having reviewed all the evidence and the clinical advice we received, we have found the Trust missed an opportunity to adequately assess and document the cause of Mrs A’s iron‑deficiency anaemia. This fell below expected standards and caused avoidable uncertainty for the family, including the loss of an opportunity to have earlier awareness of the cancer diagnosis.

3. We also found the Trust’s complaint handling fell significantly below expected standards. The delays, lack of clarity, and poor communication caused avoidable distress, frustration, and prolonged grief for Mrs K at an already difficult time.

4. These failings had a clear and meaningful impact, and the Trust has not yet done enough to put this right. For these reasons, we uphold the complaint.

5. We are making recommendations to acknowledge the failings we have identified, apologise for their impact, take steps to prevent similar issues in future, and provide a financial remedy of £1,200 in recognition of the avoidable distress and uncertainty caused. We also expect the Trust to produce an action plan to support learning and improvement.